Release of Information

I hereby request & authorize Discovery Counseling Austin and my provider to disclose AND to obtain any information they need to support my treatment and coordinate care from the following person(s) listed on this document.

Client

Client Full Name
*

Client Date of Birth

-
Month
-
Day Year

Client Phone Number
*

-
Area Code Phone Number

Entity to which client is consenting release of information To/From:

Full Name
*

Relationship

Doctor, Lawyer, Family Member, etc.

Email

example@example.com

Phone Number
*

-
Area Code Phone Number

Fax Number

-
Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Restrictions: If you want to restrict any specific information from being shared, please list your preferences here:

Only intake information, only attendance, etc.

By checking each box below, you acknowledge that you have full understanding of your consent to release information to the above person(s) and that you trust Discovery Counseling Austin and your provider(s) to follow the doctrine of consent with your written permission herein. If you wish to discuss revoking this authorization or refuse to sign this form, you can ask for assistance from your provider who can go over this information in more detail.